Northwest Community EMS System Continuing Education July 2016 CE Credit Questions page 1 of 2. Name Date Employer

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1 Northwest Community EMS System Continuing Education July 2016 CE Credit Questions page 1 of 2 Name Date Employer Note: Completion of these questions is worth one (1) CE hour (as this module was primarily psycho-motor simulated cardiac arrest team resuscitation). This may be submitted without penalty until November 30, What 3 places on the body does rigor mortis 1 first occur? Eyelids, Neck, Jaw Complete the quote from Dr. Ortinau, Of all the medical emergencies where we (EMS) make a difference, for most we just get the ball rolling. In cardiac arrest, what 2 things are known to improve outcome? In cardiac arrest, what 2 things have NOT been shown to improve outcome? 5 List the 5 components of quality CPR. 6 Are compression rates higher than 120, or less than 100, associated with a decreased likelihood of survival? Why? 7 Why is releasing completely important? When using the ResQPOD impedance threshold device what compression rates are associated with best outcome? Are there improved cardiac arrest outcomes, when using mechanical CPR devices, compared to manual CPR? In pit crew cardiac arrest resuscitation, what are the 5 roles? What should be done if only 2 rescuers are on the scene of a cardiac arrest? 12 Where should defib pads/paddles be placed? What are 2 acceptable reasons to interrupt chest compressions? Is it important to minimize pre-shock and postshock pauses in compressions? Should patients be moved with CPR in progress? Why should an OP/NPA be inserted prior to beginning BVM ventilation? When using the ResQPOD/ITD when is it more important to maintain a tight face-mask seal - during compressions or ventilations? In cardiac arrest, we own it. We are the ones that make a difference. Initial care, what we do in the field, determines outcome more than anything else. Quality CPR Defibrillation Advanced airway Transport w/ CPR in progress Rate, Depth, Release completely, Minimize interruptions, Do not hyperventilate Yes. Increased rate does not allow heart enough time to refill with blood and increased rate is associated with inadequate compression depth. To allow heart & coronary arteries to refill with blood No Compressor, Monitor, Airway, Meds, Team leader Begin compressions, call for help, defib as indicated, BLS airway mgmt until help arrives Upper chest, to R of sternum, under clavicle L of nipple in mid-axillary line (V6 position) ECG q 2 minutes ( compressor at same time) Defibrillation Yes No, unless very unique situation To minimize gastric distention compressions

2 Northwest Community EMS System Continuing Education July 2016 CE Credit Questions page 2 of What are 5 ways capnography is helpful during cardiac arrest resuscitation? In cardiac arrest resuscitation, which has the higher priority vascular access & medication administration or advanced airway placement? While one PM is obtaining vascular access (IO/IV) what can other PM s be doing to assist? When during cardiac arrest resuscitation can placement of an advanced airway be considered? 22 What is persistent/refractory VF? 23 If VF persists after 3-4 defibrillations, what should be done? 24 What are causes of PEA? 25 List 5 assessment/interventions appropriate for PEA? 26 List 4 aspects of post-rosc care What should be done post-rosc if pt is hypotensive? Is therapeutic hypothermia still highly recommended by the AHA? Why was it removed from pre-hospital care? Is re-arrest common? What type of re-arrest is most common? What can be done to promptly detect it? What should be documented on an epcr for a cardiac arrest patient? Confirm airway patency & ventilation Prevent hyperventilation Monitor compression quality Predict ROSC Identify when ROSC unlikely Vascular access & medication administration Prepare epinephrine Prepare IVF w/ pressure infuser After at least 3 min of pre-oxygenation, after epi & amiodarone (if VF) given, sooner if unable to BVM ventilate VF that occurs despite multiple defibrillation attempts Leaving 1 st set of pads on pt, attach new set of defib pads to pt in AP position, switch cable to new set, shock using new pads/placement Hypovolemia, hypoxia, hypoglycemia, hydrogen ion excess, hypo/hyperkalemia, hypothermia, tension pneumo, toxins, tamponade, thrombosis, trauma IVF bolus w/ pressure infuser, glucose, lung sounds for tension pneumo, airway/o2 supply, PMH & meds Monitor closely Assess & support BP Do not hyperventilate Acquire 12L Administer IVF until pressor (dopamine) ready, Start 2 nd IV/IO if needed Yes. Removed because no evidence of benefit when started prehospital and was distracting from other priorities like BP support and acquiring 12L ECG. Yes. PEA. Keep finger on pulse, watch O2 sat pleth ECG & EtCO2 every 2 minutes CPR started & stopped time not every 2 minutes DIANA:july 16 cecq

3 July 2016 Continuing Education Cardiac Arrest Pit-Crew Team Resuscitation Diana Neubecker RN BSN PM NWC EMSS In-Field Coordinator Objectives - Related to cardiac arrest resuscitation: 1. Discuss new knowledge. 2. Review selected key elements. 3. Identify & demonstrate treatment priorities. 4. Practice team pit-crew approach skills. 5. Improve documentation. Crew finds pt non-breathing & pulseless with unmovable jaw, so performs surgical cric Rigor Mortis At death muscles relax, then stiffen Begins in 2-6 hrs, in the eyelids, neck, and jaw; then spreads to other muscles, last in fingers & toes Onset varies w/ temp, age, physical condition and build After 24-hrs muscles relax and flaccidity develops Infant/child may not show rigor due to sm. muscle mass Cardiac Arrest Resuscitation Of all the medical emergencies where we (EMS) make a difference, for most we just get the ball rolling. In cardiac arrest, we own it. We are the ones that make a difference. Initial care, what we do in the field, determines outcome more than anything else. John M. Ortinau, MD, FACEP NWC EMSS Medical Director Do NOT delay something known to improve outcome, to do something NOT known to improve outcome Known to improve outcome Quality CPR Defibrillation Might improve outcome Medications, especially if given early NOT shown to improve outcome Advanced airway Transport w/ CPR in progress Quality CPR 1. Rate (at least 100, but less than 120) 2. Depth (2-2¼ ) Monitor Smartphone Device Metronome USE ONE! 3. Release completely 4. Minimize interruptions 5. Do NOT hyperventilate

4 Avoid too Fast Compressions Principal mechanisms thought to be responsible for producing blood flow during chest compressions: 1) direct cardiac compression 2) intrathoracic pressure Compression Rate affects Compression Depth data show that survival peaks with a chest compression rate around 120/min, with rates of 120/min or higher or less than 100/min being associated with a decreased likelihood of survival. rates were greater than 120/min in nearly one third of cases. Forward blood flow depends on venous blood filling the heart & lungs during diastole/release phase of chest compression. If release phase is too brief, blood available for forward flow during compression may be decreased. May explain findings that rates faster than 120/min are associated w/ decreased survival, as are rates less than 100/min. Chest compression rate versus chest compression depth. The stacked bar graph shows distribution of three categories of chest compression depth (< 38mm indicated in gray, 38 51mm white, > 51mm black) across categories of compression rates (< 80, 80 99, , 120 compressions/min) (n = 6,399; chi-square test, p < ). RELEASE Completely Real Time CPR Feedback Do NOT lean on chest Assure chest recoils completely after compressions Pressure between compressions creates positive intrathoracic pressure - which decreases heart & coronary artery refilling w/ blood Chest Compression Fraction (CCF) Proportion of each minute interval during which chest compressions are provided Associated with survival ResQPOD Impedance Threshold Device Circulation enhancing device Works during compressions Best outcome when compression rate /min Often expressed as percentage (%)

5 What s the story with the RQP ITD? 2015 AHA Guidelines level of recommendation Study: 8718 pts, 4345 sham, 4373 functioning ITD, did not show a benefit from ITD. No differences in adverse events (pulmonary edema, airway bleeding) between the groups. AHA Recommendation: Routine use of the ITD as an adjunct during conventional CPR is not recommended. Class of Recommendation indicates that evidence did not demonstrate benefit or harm associated with the ITD when used as an adjunct to conventional CPR. Published after 2015 Guidelines written With acceptable CPR, there is a difference Categorized as acceptable ranges: Rate: 100 ± 20% (80 120) Depth: 5 cm ± 20% (4 6 cm) 45% had acceptable CPR This analysis supports the notion that the quality of CPR needs to be taken into account during randomized controlled trials of interventions for cardiac arrest. Our analysis of the prospectively collected, well-defined ROC-PRIMED dataset showed statistically significant and clinically important interactions between the quality of CPR provided, the study interventions, and survival to hospital discharge with favorable neurological outcome. Worse Better Outcome If acceptable quality CPR, when using RQP/ITD, there is improvement in neuro intact survival 5.3. Mechanical CPR A systematic review of randomized trials of mechanical chest compression devices found no advantage to the routine use of mechanical chest compression devices for OHCA (survival to discharge/30 days (average odds ratio (OR) 0.89, 95% CI 0.77, 1.02) and survival with good neurological outcome (average OR 0.76, 95% CI 0.53, 1.11). Gates S, Quinn T, Deakin CD, Blair L, Couper K, Perkins GD. Mechanical chest compression for out of hospital cardiac arrest: systematic review and meta-analysis. Resuscitation 2015;94:91 7. If unacceptable quality CPR, better to not use the RQP/ITD Unacceptable Rate less than 80, or greater than 120 Depth less than 4 cm, or greater than 6 cm Compression fraction less than 50% Per-protocol analysis of the LINC trial observed similar four-hour survival rates between mechanical and manual CPR (23.8% vs. 23.5%, ). Rubertsson S, Lindgren E, Smekal D, et al. Per-protocol and pre-defined popu-lation analysis of the LINC study. Resuscitation 2015;96:92 9. A prospective evaluation of mechanical CPR in Vienna noted worse neurological outcomes in those receiving mechanical CPR. Zeiner S, Sulzgruber P, Datler P, et al. Mechanical chest compression does not seem to improve outcome after out-of hospital cardiac arrest. A single center observational trial. Resuscitation 2015;96: These findings reinforce the ILCOR and ERC recommendations against their routine use. Resuscitation Nov;96: Mechanical chest compression does not seem to improve outcome after out-of hospital cardiac arrest. A single center observational trial. Zeiner S, Sulzgruber P, Datler P, Keferböck M, Poppe M, Lobmeyr E, van Tulder R, Zajicek A, Buchinger A, Polz K, SchrattenbacherG, Sterz F. Pit-Crew AIM: Recently three large post product placement studies, comparing mechanical chest compression (cc) devices to those who received manual cc, found equivalent outcome results for both groups. Thus the question arises whether those results could be replicated using the devices on a daily routine. METHODS: We prospectively enrolled 948 patients over a 12 months period. Chi-Square test and Mann-Whitney-U test were used to assess differences between "manual" and "mechanical" cc subgroups. Uni- and multivariate Cox regression hazard analysis were used to assess the influence of cc type on survival. RESULTS: A mechanical cc device was used in 30.1% (n=283) cases. Patients who received mechanical cc had a significantly worse neurological outcome - measured in cerebral performance category (CPC) - than the manual cc group (56.8% vs. 78.6%, p=0.009). Patients receiving mechanical cc were significantly younger, more were male and were more likely to have bystander CPR and an initially shock-able ECG rhythm. There was no difference in the quality of CPR that might explain the worse outcome in mechanical cc patients. CONCLUSION: Even with high quality CPR in both, manual and mechanical cc groups, outcome in patients who received mechanical cc was significantly worse. The anticipated benefits of a higher compression ratio and a steadier compression depth of a mechanical cc device remain uncertain. In this study selection for mechanical cc was not standardized, and was non-random. This merits further investigation. Further research on how mechanical cc is chosen and used should be considered. Seconds make a Difference

6 Pit-Crew Roles - in order # 1 - Compressor responsive & pulse Begin Compressions # 3 - Airway Insert OP/NPA Attach BVM to RQP, capno, O2 Tight face-mask seal w/ 2 hands # 2 - Monitor Attach combo-pads to pt & monitor Take over compressions # 2 Attach defib electrodes, then takes over CC # 4 Vasc & Meds # 3 Airway Explorer #5 Team Leader # 5 - Team Leader Code Commander Coach crew & document # 4 - Meds Obtain IV/IO access Administer meds # 1 CC Best outcome when treated on-scene by 7-8 EMS rescuers (EMT s & PM s); supporting practice of sending additional vehicle to scene. Resuscitation 94 (2015) Does number of EMS personnel on scene affect outcome? Study of 16,122 cases, 7-8 EMS personnel on-scene was associated w/ highest survival compared with fewer personnel on-scene. What if only 2 responders? # 1 Insert OP/NPA Attach BVM RQP, capno, O2 Tight face-mask seal w/ 2 hands # 2 responsive & pulse Begin compressions After ECG /defib, move to airway Call for help Attach combo-pads to pt & monitor then Take over compressions Location Defib Pad/Paddle Placement Just under Clavicle Right of Sternum Defibrillation Pad Placement Upper chest, to R of sternum, under clavicle Apex of heart, L of nipple, mid-axillary line Apply firm pressure when using paddles No advantage anterior-posterior position for defib ~V6 position (L) armpit ~V6 position Mid-axillary line (L) armpit Horizontal to nipple Mid-axillary line Horizontal to nipple

7 Chest Compressions (CC) Acceptable reasons to interrupt compressions 1. ECG every 2 minutes (goal less than 5 sec) Should it be shocked? Is it organized? Goal: Minimize peri-shock pauses Minimize time from last compression to shock, and from shock to next compression Do NOT ECG during same pause as defib Change compressor at the same time If reliever NOT in place/ready to take over speak up! 2. Defibrillate (goal less than 5 sec) Do NOT ECG during same pause as defib Checking ECG during same pause as defib Increases pre-shock pause Should pts be moved w/ CPR in progress? NO (unless very unique situation), interrupts & decreases CPR quality OPA/NPA & BVM Ventilation Insert OP/NPA before beginning BVM ventilation to minimize gastric distention, vomiting & aspiration Use 2-hand method before adv. airway to maintain tight face-mask seal esp. w/ RQP/ITD during compressions Ventilation Hyperventilation is Lethal Watch both RATE and VOLUME Do NOT squeeze bag right before: ECG (can cause artifact) Defibrillation ( effectiveness) Capnography every 2 minutes to: 1. Confirm airway patency & ventilation 2. Prevent hyperventilation (shows ventilation rate) 3. Monitor compression quality 4. Predict ROSC (before pulse detected) 5. Identify when ROSC unlikely

8 NEW Priority Emphasis Complete vascular access & 1 st round meds before preparing for adv. airway placement Vascular Access - ASAP Dedicate additional personnel, if available to help 1. ID vascular access site (IV or IO) 2. Prep site w/ CHG/IPA 3. Prep 10mL NS flush, if IO 4. Prime connecting tubing, if IO 5. Prep IVF & tubing 6. Insert & secure IO (or IV) 7. Prep epinephrine 8. Prep amiodarone 9. Place IVF in pressure infuser, if IO Medications 1 st med all pulseless = vasopressor Prepare/administer epinephrine ASAP Prepare meds in advance, so ready when time to give Give based on last ECG do NOT delay until next ECG Follow w/ ml IVF bolus If extremity IV: elevate x 20 sec We found that time to vasopressor administration is significantly associated with ROSC, and the odds of ROSC declines by 4% for every 1-minute delay between call receipt and vasopressor administration. Amiodarone possibly most beneficial if given early Scenario Prep Meds Before Need Time EtCO2 ECG DF Med Administration What med person doing? VF 120j Prepare Epi, give ASAP, then prepare amiodarone AS Epi 1mg Prep next epi VF 150j Amio 300mg Give amio, then prep next amio IVR Epi 1mg Give epi, then prep next epi AS VF 200j Epi 1mg & Amio 150mg Give epi & amiodarone Then prep next epi IVR IVR Epi 1mg Give epi & then prep next epi VF 200j AS Epi 1mg Give epi & then prep next epi AS VF 200j Epi 1mg Give epi & the prep next epi AS ST Get dopamine out while BP

9 Medication Double Cross-Check Beyond the Rights.. Advanced Airways (ETI, KLTSD) No evidence to support early placement Preoxygenate for at least 3 min prior Consider after epi & amiodarone (if VF) given Check meds w/ another PM prior to giving Insert sooner - if unable to BVM Avoid interrupting compressions Ventricular Fibrillation (VF) Recurrent VF Other rhythms between episodes of VF Refractory/Persistent VF VF despite multiple defibrillation attempts Persistent/Refractory VF Defib goal - stop electrical activity, to allow normal pacemakers to function VF has different vectors While anterior-lateral placement works for most VF. If it does not, changing pad placement has been shown to be effective Persistent/Refractory VF After ~3 rd or 4 th defibrillation Leaving original (anterior-lateral) electrodes in place Apply fresh/new set defib pads in Anterior-Posterior position Minimize compression interruption placing posterior pad Switch cable from 1 st set to 2 nd set electrodes Defib using - new pads- in AP position 1 st set 2 nd set

10 Pulseless Electrical Activity PEA is not a rhythm; any rhythm can be PEA PEA can be fast or slow; wide or narrow Pseudo vs true PEA (cannot [yet] determine in field) 55% had mechanical activity ( pseudo PEA ) and a much higher rate survival to discharge. Flato UA, Paiva EF, Carballo MT, Buehler AM, Marco R, Timerman A. Echocardiography for prognostication during the resuscitation of intensive care unit patients with non-shockable rhythm cardiac arrest. Resuscitation 2015;92:1 6. HypoVOLEMIA HypOXIA HypoGLYCEMIA Hydrogen ion Hypo/hyperKALEMIA HypoTHERMIA Tension pneumo Toxins Tamponade Thrombosis Trauma IV begin rapid IVF bolus using pressure infuser Glucose? hypoglycemia Lungs? tension pneumo Oxygen? airway, O2 supply PMH & meds? renal failure, toxins 1. Monitor closely Post ROSC Care 2. BP support HIGH priority; maintain heart & brain perfusion & support BP/MAP If hypotensive: Administer IVF until Dopamine ready Begin DOPAMINE, titrate to response Start additional IV, if needed 3. Do NOT hyperventilate - even if ETCO 2 4. Acquire 12L Prime this line/space w/ dopamine regulate DOPAMINE drip rate here turn OFF connect mini-drip tubing here Therapeutic Hypothermia Not harmful; Still highly recommended by AHA Removed from prehospital SOP s because no evidence of benefit when given prior to hospital arrival Was distracting from other priorities in prehospital care (BP support, 12L ECG) 2015 Recommendations We recommend that comatose (ie, lack of meaningful response to verbal commands) adult patients with ROSC after cardiac arrest have TTM (Class I, LOE B-R for VF/pVT OHCA; Class I, LOE C-EO for non-vf/pvt (ie, nonshockable ) and inhospital cardiac arrest).of note, there are essentially no patients for whom temperature control somewhere in the range between 32o C and 36o C is contraindicated. Hypothermia in the Prehospital Setting - When cooling maneuvers were initiated in the prehospital setting, neither survival nor neurologic recovery differed for any of these trials alone or when combined in a meta-analysis. Current evidence indicates that there is no direct patient benefit from these interventions and that the intravenous fluid administration in the prehospital setting may have some potential harm, albeit with no increase in overall mortality. Rearrest Re-arrest occurs in ~38%, most often in first 10 minutes Most common type: PEA (so ECG rhythm may not change) Risk w/ re-arrest: Not detected quickly, not treated aggressively Detected quickly & treated aggressively; does not worsen outcome! Keep finger on pulse; watch O2 sat pleth on monitor to detect Documentation Key Points Document ECG & EtCO2 - every 2 minutes Not BP & pulse; not checked every 2 min Pulse is a palpable pulse (not HR on ECG) CPR started when started and stopped due to ROSC or TOR (termination of resuscitation) Not every 2 minutes with rhythm check O2 sat should not be documented during CPR Number is meaningless without a pulse

11 time Consider Compressions started HypoVOLEMIA (IVF 20mL/kg) Tension pneumo ECG monitor/defib electrodes on HypoGLYCEMIA ( glucose) Toxins Airway: OPA/NPA in place HypOXIA ( O2) Tamponade BVM ventilation w/ oxygen Hypothermia Thrombosis RQP/ITD & Capnography on BVM Hypo/hyperkalemia Trauma Vascular Access IO-IV H ion/acidosis time ETCO2 ECG rhythm Defib J Med given Notes ROSC Check & support BP If hypotension: IVF bolus while prep dopamine Monitor VS & ECG closely Check O2 sat 12-L ECG DIANA:ca-worksheet-16

12 # 3 Insert OP/NPA Attach RQP/ITD & capnography to BVM w/ O2 Maintain tight 2-hand face-mask seal during compressions & ventilations Compressor squeezes bag, after compression sets, until advanced airway placed # 1 begin CHEST COMPRESSIONS # 2 TURN ON MONITOR & ATTACH ELECTRODES/DEFIB PADS (Will relieve compressor) # 4 Establish IV/IO Administer MEDICATIONS # 5 TEAM LEADER Code Commander DIANA:pit-crew team-resuscitation